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Nightmare Disorder
DSM-IV Diagnostic Criteria A'''. Repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely frightening dreams, usually involving threats to survival, security, or self-esteem. The awakenings generally occur during the second half of the sleep period. '''B. On awakening from the frightening dreams, the person rapidly becomes oriented and alert (in contrast to the confusion and disorientation seen in Sleep Terror Disorder and some forms of epilepsy). C'''. The dream experience, or the sleep disturbance resulting from the awakening, cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. '''D. The nightmares do not occur exclusively during the course of another mental disorder (e.g., a delirium, Posttraumatic Stress Disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Differential Diagnosis Sleep Terror Disorder Nightmare Disorder should be differentiated from Sleep Terror Disorder. Both disorders include awakenings or partial awakenings with fearfulness and autonomic activation, but can be differentiated by several clinical features. Nightmares typically occur later in the night duration REM sleep and produce vivid dream imagery, complete awakenings, mild autonomic arousal, and detailed recall of the event. Sleep terrors typically arise in the first third of the night during stage 3 or 4 NREM sleep and produce either no dream recall or single images without the storylike quality that is typical of nightmares. Sleep terrors lead to partial awakenings in which the individual is confused, disoriented, and only partially responsive and has significant autonomic arousal. In contrast to Nightmare Disorder, the individual with Sleep Terror Disorder has amnesia for the event on awakening in the morning. Breathing-Related Sleep Disorder, Narcolepsy, and Panic Attacks Breathing-Related Sleep Disorder can lead to awakenings with autonomic arousal, but these are not accompanied by recall of frightening dreams. Nightmares are a frequent complaint of individuals with Narcolepsy, but the presence of excessive sleepiness and cataplexy differentiates this condition from Nightmare Disorder. Panic Attacks arising during sleep can also produce abrupt awakenings with autonomic arousal and fearfulness, but the individual does not report frightening dreams and can identify these symptoms as consistent with other Panic Attacks. The presence of complex motor activity during frightening dreams should prompt further evaluation for other Sleep Disorders, such as "REM sleep behavior disorder" (see Parasomnia Not Otherwise Specified). Substance-Induced Sleep Disorder, Sleep Disorder Due to a General Medical Condition, and delirium Numerous medications that affect the autonomic nervous system can precipitate nightmares. Examples inlcude L-dopa and other dopaminergic agonists; beta-adrenergic antagonists and other antihypertensive medications; amphetamine, cocaine, and other stimulants; and antidepressant medications. Conversely, withdrawal of medications that suppress REM sleep, such as antidepressant medications and alcohol, can lead to a REM sleep "rebound" accompanied by nightmares. If the nightmares are sufficiently severe to warrant independent clinical attention, a diagnosis of Substance-Induced Sleep Disorder, Parasomnia Type, may be considered. Nightmare Disorder also should not be diagnosed if the disturbing dreams arise as a direct physiological effect of a general medical condition (e.g., central nervous system infection, vascular lesions of the brain stem, general medical conditions causing delirium). If the nightmares are sufficiently severe to warrant independent clinical attention, Sleep Disorder Due to a General Medical Condition, Parasomnia Type, may be considered. Although nightmares may frequently occur during a delirium, a separate diagnosis of Nightmare Disorder is not given. Other mental disorders Nightmares occur frequently as part of other mental disorders (e.g., Posttraumatic Stress Disorder, Schizophrenia, Mood Disorders, other Anxiety Disorders, Adjustment Disorders, and Personality Disorders). If the nightmares occur exclusively during the course of another mental disorder, the diagnosis of Nightmare Disorder is not given. Normal nightmares Many individuals experience an occasional, isolated nightmare. Nightmare Disorder is not diagnosed unless the frequency and severity of nightmares result in significant distress or impairment. DSM-5 Diagnostic Criteria A'''. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode. '''B. On awakening from the dysphoric dreams, the individual rapidly becomes orientated and alert. C'''. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. '''D. The nightmare symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication). E'. Coexisting mental and medical disorders do not adequately explain the predominant complaint of dysphoric dreams. ''Specify if: * '''During sleep onset Specify if: * With associated non-sleep disorder, including substance use disorders * With associated other medical condition * With associated other sleep disorder Note: Record also the relevant associated mental disorder, medical condition, or other sleep disorder immediately after nightmare disorder in order to indicate the association. Specify if: * Acute: Duration of period of nightmares is 1 month or less. * Subacute: Duration of period of nightmares is greater than 1 month but less than 6 months. * Persistent: Duration of period of nightmares is 6 months or greater. Specify if: * Mild: Less than one episode per week on average. * Moderate: One or more episodes per week but less than nightly. * Severe: Episodes nightly. Differential Diagnosis Sleep terror disorder Both nightmare disorder and sleep terror disorder include awakenings or partial awakenings with fearfulness and autonomic activation, but the two disorders are differentiable. Nightmares typically occur later in the night, during REM sleep, and produce vivid, storylike, and clearly recalled dreams; mild autonomic arousal; and complete awakenings. Sleep terrors typically arise in the first third of the night during stage 3 or 4 NREM sleep and produce either no dream recall or images without an elaborate storylike quality. The terrors lead to partial awakenings that leave the individual confused, disorientated, and only partially responsive and with substantial autonomic arousal. There is usually amnesia for the event in the morning. REM sleep behavior disorder The presence of complex motor activity during frightening dreams should prompt further evaluation for REM sleep behavior disorder, with occurs more typically among late middle-age males and, unlike nightmare disorder, is associated with often violent dream enactments and a history of nocturnal injuries. The dream disturbance of REM sleep behavior disorder is described by patients as nightmares but is controlled by appropriate medications. Bereavement Dysphoric dreams may occur during bereavement but typically involve loss and sadness and are followed by self-reflection and insight, rather than distress, on awakening. Narcolepsy Nightmares are a frequent complaint in narcolepsy, but the presence of excessive sleepiness and cataplexy differentiates this condition from nightmare disorder. Nocturnal seizures Seizures may rarely manifest as nightmares and should be evaluate with polysomnography and continuous video electroencephalography. Nocturnal seizures usually involve stereotypical motor activity. Associated nightmares, if recalled, are often repetitive in nature or reflect epileptogenic features such as the content of diurnal auras (e.g., unmotivated dread), phosphenes, or ictal imagery. Disorders of arousal, especially confusional arousals, may also be present. Breathing-related sleep disorders Breathing-related sleep disorders can lead to awakenings with autonomic arousal, but these are not usually accompanied by recall of nightmares. Panic disorder Attack arising during sleep can produce abrupt awakenings with autonomic arousal and fearfulness, but nightmares are typically not reported and symptoms are similar to panic attacks arising during wakefulness. Sleep-related dissociative disorders Individuals may recall actual physical or emotional trauma as a "dream" during electroencephalography-documented awakenings. Medication or substance use Numerous substances/medications can precipitate nightmares, including dopaminergics; beta-adrenergic antagonists and other antihypertensives; amphetamine, cocaine, and other stimulants; antidepressants; smoking cessation aids; and melatonin. Withdrawal of REM sleep-suppressant medications (e.g., antidepressants) and alcohol can produce REM sleep rebound accompanied by nightmares. If nightmares are sufficiently severe to warrant independent clinical attention, a diagnosis of substance/medication-induced sleep disorder should be considered.